However, the positive outcomes from multilayer foam dressings was just emerging!

Joyce Black, PhD, RN, CWCN, FAAN University of Nebraska Medical Center Omaha, NE Study of Adult Nursing Units using NDNQI data 1381 hospitals from all 50 states from 2008-2010 Outcome data, changes in rates after ruling/payment change of: Pressure ulcers Injurious falls Central line associated bloodstream infections Catheter-associated urinary tract infections Waters, Daniels, Bazzoli et al. Effect of Medicare s nonpayment for Hospital Acquired Conditions: lessons for future policy. JAMA 2015, 175 (3), 347-354 jblack@unmc.edu 1 jblack@unmc.edu 2 11% reduction in CLABSI s - sustained 10% reduction in CAUTI s sustained.5% reduction in rates of falls - flat 1% reduction in rates of stage III and IV pressure ulcers sustained slow decline We acknowledge the concern that not all pressure ulcers are avoidable. However, we believe improving screening to identify ulcers on admission will improve quality of care. Institutes of Medicine, 2007 Standardized practices had been developed and tested for CLABSI and CAUTI Practice change was fewer steps Practice change may have only had to occur once or once a day Practice change involved fewer people and products jblack@unmc.edu 3 jblack@unmc.edu 4 Pressure injury reduction requires more than admission assessments to change the outcomes! Processes of care are more nebulous with some decisions made at the bedside Nurses carry out assessment and planning but may not do the turning However, the positive outcomes from multilayer foam dressings was just emerging! jblack@unmc.edu 5 Reduce the intensity of the pressure Support surfaces Multilayer foam dressing to reduce the pressure Offload the heel Reduce the duration of the pressure Turning and repositioning Reduce the effect of shear Keeping the head of the bed low Multilayer foam dressings to reduce shear forces Improve the health of the skin Giving nutrition and hydration Keeping the skin clean and dry Protecting damaged skin jblack@unmc.edu 6 1

Optimal Patient Outcomes Consistent Care Delivery Quality/Performance Strategy Organizational Support on all levels EB Practice for HAPI Prevention jblack@unmc.edu 7 jblack@unmc.edu 8 Consider applying a polyurethane foam dressing to bony prominences (e.g., heels, sacrum) for the prevention of pressure ulcers in anatomical areas frequently subjected to friction and shear (B/1) Lack of clarity in discussion about actual structure of dressing Not all studies cited used polyurethane foam Many polyurethane foam dressings on the market Important to know how they work and if they can reduce pressure, shear or microclimate Dressings do not replace the rest of prevention! (C/1) Use of prophylactic dressings over bony prominences reduced the relative risk of pressure ulcers by 0.21 (p = 0.0006) Moore and Webster, The Cochrane Database of Systematic Reviews, 2013, 8 (8) Use of prophylactic dressings reduce pressure injury in immobile patients Clark, Systematic review of the use of dressings in the prevention of pressure ulcers, Int Wound J 2014,11,(5),460-471 jblack@unmc.edu 9 jblack@unmc.edu 10 What is the effectiveness of implementing a single PI prevention in ICU compared to bundled intervention? From; Tayyib, 2016, Systematic Review in Worldviews On Evidence Based Nursing jblack@unmc.edu 11 Santamaria (IWJ, 2015) Dressing group 7/161 Control group 27/152 Diff stat sig at p = 0.002 Kalowes (AJCC, 2016) Dressing group 1/184 Control group 7/183 Diff stat sig at p = 0.001 Quili (Chin J MS Nur, 2010) Dressing group 0/26 Control group 3/26 8/371 with drsg ulcerated 37/361 without drsg ulcerated jblack@unmc.edu 12 2

Thul in ICU (2015) Dressing 1/39 Control 19/83 Park in ICU (2014) Dressing 3/52 Control 23/50 Brindle in OR/ICU (2012) Dressing 1/50 Control 4/35 6 /337 with dressings ulcerated 67 /392 without dressings ulcerated Cubit in General care (2012) Dressing 1/51 Control 6/58 Brindle in ICU (2010) Dressing 0/41 Control 3/52 Castelino in OR Dressing 0/104 Control 12/114 21 studies of patients in ICU Inconsistent reporting of baseline and numbers of patients being compared Baker, 2014; Bateman, 2014; Bateman, 2013; Boesch, 2012; Cano, 2011; Castelano,2012; Chaiken,2012; Edwards, 2014; Gentry, 2010; Haggard, 2014; Hasley, 2015, Hsu, 2010; Johnstone, 2013; Kiely,2012; Koener, 2011; Kuo, 2014; Lentz, 2013; Muldoon,2010; Santamaria, 2015; VanCapellen, 2011; Walsh, 2012 jblack@unmc.edu 13 jblack@unmc.edu 14 100 patients planning on cardiac surgery Randomly dressed with Mepilex Border Sacrum preoperatively 15 lost to follow up 50 intervention 35 control Following surgery, control group had dressing removed 4 of 35 ulcerated mostly DTPI Treatment group stayed dressed 1 ulcerated after 12 days Determining what is an OR acquired ulcer Seldom visible at end of case Cautery, device and prep solution burns visible early How many of your PrI start in OR? Prep solution burn Brindle and Weglin, JWOCN 2912 jblack@unmc.edu 15 This burn occurred in the OR; visible at end of case 16 Braden not predictive (He, Lie, 2014) Anesthesia Severity Assessment Scores (ASA) ASA 3 higher risk (O Brien, 2013) 1 pt increase in ASA increases odds by 149% (Fred, 2012) Use of CP bypass Time in OR 2.5 hours of more Every 30 after 4 hours increases risk by 33% (Schoonhoven, 2002) Position on OR table Prone Low BMI/High BMI (O Brien, 2012) 17 jblack@unmc.edu 18 3

Open heart cases baseline was16.7% incidence 71 patients having cardiac surgery Following use of the dressing, zero patients ulcerated Prone cases 104 dressed Zero ulcers 114 without dressings 12 ulcers Braden does not predict heel ulcer risk well Braden score 15 +/- 3 Aspects missing Leg mobility Can vs does Diabetes or Peripheral neuropathy Vascular status or perfusion jblack@unmc.edu 19 Delmore, B. Risk factors associated with heel pressure ulcers in hospitalized patients. JWOCN 2015, 42 (3), 242-248 Does the patient move legs independently? Does versus can Does the patient have normal or delayed capillary refill? Palpable pulses? Does the patient have normal sensation? Does the patient wear TEDs? When these factors are present patients are at risk Heels need to be floated from the bed Boots can be used Often cannot ambulate Often too hot to wear Pillows can be used Don t stay under the calf Migrate to under the knee Fall off of the bed Don t fully elevate the heel Are placed under the heel As organizational Pressure Ulcer rates decreased MDR PrIs became much more apparent MDRPrIs often were misidentified or excused That s just what happens when... Not typically tracked, trended or reported May not be easy to prevent device may be an essential diagnostic/therapeutic component of treatment Although most are avoidable, not all are What is a medical device? Fit the device to the patient Measure devices for proper fit Pretreat the skin with thin foam dressings Work with other disciplines to assure this happens Remove or move daily to see the skin Be aware of edema Devices can be lost in bariatric patient skin folds 4

Not much data to support benefits of one surface over another General recommendations ICU = high immersion with low air loss General units = foam with alternating pressure Bariatric beds for those over 350 lbs Early mobility programs call for extend sitting Position patient for stability and ability to perform usual activities (SoE= C; SoR = ) Tilt the seat back to prevent sliding Place feet on foot rest or foot stool jblack@unmc.edu 25 This patient is not safe in this chair, nor is he sitting on the chair cushion Are not designed for pressure redistribution Need a seat cushion Ulcers develop after 4-6 hours of sitting Patient needs repositioning hourly if not moving or restrained Call, Pedersen, Bill, et al. Enhancing pressure ulcer prevention using wound dressings: What are the modes of action? Int Wound J 2015, 12, 408-413 jblack@unmc.edu 28 A powerful, validated tool for analyzing tissue deformation Finite Element Modelling Red indicates elevated stress levels Blue indicates no increase in stress Multinational expert panel examined evidence on dressings for PIP and MDR PI prior to guidelines in 2014 Black, IWJ 2013 Black, IWJ 2014 Advocated for Mepilex dressings to prevention Within Wound care FE modelling can facilitates quantification of internal strains and stresses in weight bearing parts (heels and buttocks) Levy & Gefen, 2016 jblack@unmc.edu 30 5

Body position: clinical practice vs standard 1 Study of 74 patients in which the change in body position was recorded every 15 minutes for an average observation time of 7.7 hours 49.3% of observed time showed no body position change for >2 hrs, and 2.7% had every-2-hour demonstrable body position change Positioning prevalence 2 Prospectively recorded, 2 days, 40 ICUs in the United Kingdom Average time between turns, 4.85 hours jblack@unmc.edu 31 1.Krishnagopalan S, et al. Crit Care Med. 2002;30:2588-2592. 2.Goldhill DR, et al. Anaesthesia. 2008;63:509-515. Q 2 hr turning with interface pressure map to highlight areas of pressure Sig reduction in PI over stage 2 Behrendt, 2014 Q 2hr turning with a turn team Sig reduction in PI over stage 2 Still, 2014 Study of residents in long term care on foam mattresses 942 Residents at moderate to high risk for PI Turned randomly Q 2,3 and 4 hrs Compliance with turning measured Outcomes Pressure injury formation was the same at all frequencies Q 2 hr = 2.5% Q 3 hr = 0.6% Q 4 hr = 3.1% Pressure injury formation did not differ by risk High risk = 1.8% Moderate risk = 2.1% Bergstrom, et al, 2013 JAGS jblack@unmc.edu 33 Turning to 30 degrees may be difficult Quality of pillows Number of pillows Use of wedges Use of turning and positioning systems Improved outcomes with use of a turn and position system (Powers, 2016) Fewer pressure ulcers (6 in SOC, 1 in PPS, p =.042) Angle of turn better (31 in PPS, 22 in SOC) Patients remained in position after 1 hour Incontinent patients risk for PI higher Prevalence increased from 4.1% to 16.3% Incidence also higher from 2.6% to 13.6% Multiple layers of linen each increase the pressure on the sacrum regardless of HOB elevation Pressure at sacrum on LAL increased from 20 to 64% Pressure at sacrum on foam increased from 6 to 29% Lachenbruch, Ribble. Pressure Ulcer Risk in the Incontinent Patient. JWOCN. 2016, 43 (3), 235-241. Williamson, Lachenbruch, The effect of multiple layers of linens on surface interface pressure: results of a laboratory study. Ostomy Wound Management 2013, 59 (6), 38-47jblack@unmc.edu 36 6

Recognize their world view Numbers and dollars Be aware of pressure injury data in your facility Move root cause analysis findings into quality improvement plans How many of your PI start in OR? ER? ICU? Target education and interventions to the staff in high risk areas Present current HAPI/FAPI rates and cost Stage 1 and 2 = $2,770.54 Stage 3 and 4 = $71,500.00 to $127,000.00 Cost Data from: Padula, Mishra, Makic et al. Improving the quality of pressure ulcer care with prevention: A cost effective analysis. Med Care 2011, 49 (4), 385-392 Brem, Maggi, Neirman et al. High cost of stage IV pressure ulcers. Am J Surg,2010 200 (4), 473-477 jblack@unmc.edu 37 jblack@unmc.edu 38 Current hospital rate is 2.5% 2% stage 1 and 2 and 0.5% stage 3 and 4 Annual acute admissions are 24,557 491 stage 1 and 2 at $2,771. = $1,360,561 61 stage 3 and 4 x $71,500. = $4,361,500 61 stage 3 and 4 x $127,000. = $7,747,000 Total spent on HAPI last year = $13,469,061.00 Usage and cost data for high cost and/or high volume items Clinician request for new products World class companies provide 40 hours of training for their reps yearly How much training does your team get? jblack@unmc.edu 39 jblack@unmc.edu 40 Create a list of attributes for the product What do you want the product to do? Or not do? Create a grid that lists Clinical benefits Safety features Ease of use Look at 360 degrees of product use Involve direct caregivers (Magnet) Development of grid provides data devoid of opinion and emotion Decision becomes transparent Cost per item now x volume = annual expense Cost per new item x volume (can remain the same or change) = projected expense Hopefully, will show annual savings jblack@unmc.edu 41 jblack@unmc.edu 42 7

What is the cost of the problem you are trying to solve? What is your annual pressure ulcer incidence and actual number of patients with ulcers? What are pressure ulcers costing your system? Compute the number of cases you would need to prevent to recoup your cost Look for studies that show Number Needed to Treat (NNT) Values the number of patients you need to treat to prevent one additional bad outcome (pressure ulcer) Study of silicone dressings for prevention of pressure ulcers in ICU reported a NNT of 10 10 patients would be treated with dressings to prevent 1 pressure ulcer (Santamaria, 2013) jblack@unmc.edu 43 jblack@unmc.edu 44 Team needs to examine options for products Measure products performance and attributes against the grid Choose best 2-3 Ask companies to trial the products Will need staff training on products Monitor performance of new product Is it doing what you want it to do? Are you seeing the results you want to see? Root Cause Analysis on all Full Thickness HAPI Goal to determine when and where ulcer began Not to blame, but to guide care and focus education Start with first notation of PI, stage, location Go back into the record and examine events 48 hours for DTPI 72-96 hours for Stage 3,4 and Unstageable Consider location of ulcer and determine position of patient at the time pressure was applied to body Ask could anything been done differently at that time? jblack@unmc.edu 45 jblack@unmc.edu 46 Guide Communication about Risk Plans How does the bedside caregiver know how, when and where to position patient? Do staff know how to turn patients without causing back injury? Does nurse know and when to examine skin beneath preventive dressing? How does the nurse obtain speciality beds during off hours? How well is nutrition being addressed? How is skin care being provided? And by whom? Additional training Information available in real time Additional recognition This button became a coveted item Several have gone on to become wound nurses! jblack@unmc.edu 47 jblack@unmc.edu 48 8

Optimal Patient Outcomes Consistent Care Delivery Quality/Performance Strategy Organizational Support on All Levels EB Practice for HAPI Prevention jblack@unmc.edu 49 9